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San .&uin County Environmental Health•partment <br /> GREEN FORM <br /> DATE 11I ���' MASTER FILE RECORD INFORMATION ITMFRrr <br /> <..enpn ague Fran Pun nee na,v OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWING PROPERTY OWNER INFORMATION; CHECYTIF OWNER Cuxa£NrcrppoNnc£wnN EHD <br /> PROPERTVOWNERNAME 'L 1r✓Le fol J(,CS}} PHONE 4105- DO p11 <br /> First Ml Last <br /> Busuisss NAME �Y.. J, tJ rJ ,_ (I l _e _ $OCSEC/TAXID# <br /> OvnIer Horne Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address 194; N- o, S. / Ste • L <br /> Mailing Address CityState Cry Zip q og z � <br /> TvPFnFn1AoNFRcsKIP <br /> CORPORATION❑ INDMDUALX, PARTNERSHIPFED AGENCY El OTHER❑ <br /> FACILITY FILE <br /> FA0Ur Y ID# CROSS REF ID# I ACCOUM ID lF INV# <br /> rDmPiETff7NFlcOLLOWING BUSINESS / FACILITY I SITE rNFORM710N.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NDFQ <br /> Is tills an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/FACRTrY/SITENAME r y� 1 <br /> SREADDRESS 5o55 E, IAOL7A✓� ST'• SURE# BUSINESS PHONE <br /> Cm STATE l•/1dr` <br /> Z. 9C57-1S <br /> BOARD OF SUPERVISORISTR <br /> DICT —TLJV\ LO TfON CODE HEMS REN2 <br /> Mailing Address ifDIFFERENTftom FadWAddress Attention:or Care Of(optional) <br /> Iq,4-4 N. C a1 Fm tic. SA . I S4e - G C_yv es+ \fasi� <br /> Mailing Address City 54VC&+ V\ STATE CSI ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUsniess NAME , f Attention:or Care Of (optionaD <br /> Ivy �. Ay�.At.�EY� •t l�f-SSOG . �1-jF-tan: 1 9-aLC--O <br /> Mailing Address 610'2- lP'dyS +,.AeJ IPHONE <br /> C, LEI lu STATE cA zm Cj 5 7,4 b <br /> AccoL q A^^eKF for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> for F TNr.AND romp[iANrr Aca NOwi EDGMFW: ],the undersigned Applicant,certify that I am the Owaeq Operator,or Authorized Agent of this Business,and I acknowledge that all P£RAffr FEES, <br /> PENALTIES,ENFORCEMENTCHA.YGES and/or HOUnYCHARGES asamciated with this operation will be billed to meat the address identified above as the Ac UvrAnnRvcc for this site. I also certify that <br /> all information provided on this application is true and correct;and that ail regulated aadvUirA will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulmions. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> P Psa PRINT SIGNATURE <br /> APPLICANT NAME A'hI��1 �0.Gt-O <br /> TITLE F.yLJWbNt'�DAn -' Sp�-c.ir,J-A--S1' roOT«o aEo"aEoi �501�3583 <br /> Approved BYI Data Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />